Maxillofacial Injury

 

This injury can present with an apparently frightening clinical picture. Do not panic! Traumatic injuries to the facial structures may be classified as:

• Soft tissue injuries +- tissue loss
• Hard tissue injuries +-bone loss
• Combined soft and hard tissue injuries.

Management

1. The management principles of maxillofacial injuries are:
2. Advanced trauma life support (ATLS) principles (ABCDE)
3. Restore occlusion
4. Restore function
5. Restore aesthetics
6. A thorough history and examination is paramount to the management of maxillofacial injuries.

NOTE: Patients with maxillofacial injury require immediate referral to higher levels for appropriate management.

ATLS

Primary Survey

1. Airway+Cervical spine control: Note that maxillofacial injuries both soft tissue and hard tissue may compromise the airway.

• If the palate is collapsed on the roof of the mouth, scoop with finger and try to elevate.
• If the tongue is pushed back in the direction of the pharynx, pull forward with forceps.
• Apply suture to hold in place if need be. Lay patient on the side.
• With severe nose injury, such to cl;ear the blood and insert nasopharyngeal tube if need be. Take precautions as above for possible neck injuries.
• If needed in very severe injury, perform tracheostomy with a cuffed tube.
• Apply local pressure or nasal packs soaked in liquid paraffin.
• Perform direct suture of spurting bleeders

1. Breathing

• Rule out other injuries such as head injury or chest injury that may impair breathing;relevant radiographs such as chest radiograph and CT scan of the head should be taken.
• If the patient is not breathing or oxygen saturations are low, intubate and ventilate.
• For chest injury management(Refer to chest injuries)

1. Circulation

• Monitor vital signs such as BP and pulse rate, which are pointers to impending or established shock;also monitor urine(insert a urinary catheter if the patient is unconscious).
• Give antibiotics Ceftriaxone 2gm IV 8 hourly+metronidazole 500mg IV 8 hourly until the situation is managed.
• Administer fluids to maintain haemodynamic stability.
• Monitor fluid management as above.
• Give tetanus toxoid 0.5ml IM STAT.

1. Disability

• Check for consciousness and other neurological deficits(Check out Glasgow Coma Scale/GCS) and examination of all cranial nerves.

Glasgow Coma Score

Dcore=E+M+V(the higher the score the better  the prognosis).

Note: Trend is more important than the present level of consciousness.

 

Resuscitation

Arrange transport with adequate resuscitation equipment if at level 4. Ensure communication with the receiving facility has been made.

Secondary Survey

At level 5 and 6, management should be as above plus secondary survey to detail all injuries and to do specific investigations. This helps in prioritizing treatment.

Definitive Management

SOFT TISSUE INJURIES

As above plus:

• Tetanus toxoid 0.5 ml STAT.
• Rabies vaccine in case of animal bites(see management).
• Antibiotic therapy(see management of orofacial; fractures in dental and orofacial conditions).
• Through debridement of necrotic tissues and surgical toilet; all vital structures that are injured such as the parotid duct, facial nerve, and naso lacrimal duct should be repaired.
• Primary closure if there is adequate tissue for approximation; plan for wound cover with skin graft of flaps if there is still tissue loss.

NB:Al;ways rule out underlying bone injury by taking appropriate radiographs.

HARD TISSUE INJURIES

These may be classified as:

1. Dentoalveolar
2. Mandibular fractures
3. Midface fractures (Le Forte i, ii,and iii)
4. Panfacial fractures
5. The bones of the midface tend to stick out and thus prone to being injured. The nose, zygoma, and mandible are the most prone to injury, with maxillary bone injuries being relatively less common and more complicated.

 

DENTOALVEOLAR FRACTURES

This is more common in children but can occur in adults.

• Check for missing teeth/fillings to rule out inhalation(take chest x-ray, abdominal x-ray).
• For mobile teeth, rule out fractures of the root using radiographs such as intra oral periapical(IOPA), upper or lower standard occlusal or an orthopantomograms(OPG). Then reposition and splint. Teeth that have very poor support or are infected should be extracted.
• For alveolar fractures, reduce, and splint with composite resin, dental wires,(see), arch bar, or acrylic resin splints. Fixation should be maintained for 4-6 weeks in adults and 2-3 weeks in children.(Stainless steel wire 0.5mm)
• Put the patient on a soft diet.
• Clean and repair associated soft tissue injuries of the gingivae and lips.
• Give antibiotic cover(see management of orofacial fractures in dental and orofacial conditions), analgesics, and oral mouth wash.

 

MANDIBULAR FRACTURES

• These may involve any part of the mandible-the symphysis, parasymphysis, body, angle, ramus, condyle,and coronoid.
• They may also be displaced or undisplaced, depending on the pull of the muscles attached to the mandible.
• Plain radiographs demonstrated these fractures well-OPG, PA mandible(to assess linguo-buccal displacement), lower standard occlusal, lateral views.

Management

1. Closed reduction-Indications(NB:these are not absolute indicators)

• Undisplaced fractures involving the dentate mandible, children in developing dentition and
• Severely atrophic edentulous mandible.

1. Maxillo-mandibular fixation (MMF) for 6 weeks; 10-14 days for children. This is done using arch bars, eyelets, or Ivy loops(stainless steel wire 0.0mm)
2. Lingual-labial occlusal splints
3. Circum-mandibular wiring

• Gunning splints
• Antibiotic cover syrup amoxicillin 500mg 8 hourly orally and metronidazole 400mg hourly orally.
• Normal saline rinse or chlorhexidine 0.2% mouthwash.

1. Open reduction and internal Fixation(ORIF)

 

Indications:

• Displaced unstable fracture segments;
• Associated midface fractures;
• When MMF is contraindicated such as in epileptics, mentally handicapped.

Treatment

Semi-rigid fixation with trans-osseos wires(osteosynthesis)

Lag screws

Plates and screws; load sharing plates or load bearing plates (for edentulous atrophic mandible, comminuted and defect fractures).

 

MIDFACE FRACTURES

Investigations include plain radiographs: Occipito-mental view(OMV), PA skull, OPG), CT scan

 

Treatment

1. MMF+suspension wires
2. ORIF-semi-rigid fixation with trans-osseous wires-rigid plating with mini plates(1.5 and 2.0mm plates)

 

ZYGOMATIC COMPLEX FRACTURES

Investigations include OMV, submental vertex(for zygomatic arch fractures), CT scan (axial, coronal cuts+3D reconstruction)

Treatment

1. Limited access treatment(reduction without fixation) for medially displaced fractures without communition

• Gilles technique(through temporal region)
• Keen technique(lateral eyebrow approach)
• Dingman technique(lateral eyebrow approach)

1. ORIF for laterally displaced fracture and those with comminutions

• Semi-rigid fixation with trans-osseous wires
• Rigid fixation with miniplates(1.5 and 2.0mm plates)

1. Orbital fractures

• Eye examination is mandatory.
• If no ophthalmoplegia and fracture is minimally displaced, no treatment.
• If there is entrapment of orbital contents or muscles, ORIF is done.
• Miniplates are used for the orbital rims.
• Consult ophthalmic surgeon.